Patient Biographical Information
Patients 18 and Over
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
Marital Status:
Married
Divorced
Widowed
Single
*Address:
*City:
*State:
*Zip:
*This form is being completed by:
Self
Spouse
Other
*If other:
*Main Phone:
*Cell Phone:
*Email:
Employer:
*Occupation:
Work Phone:
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
What is the patients main orthodontic concern?
Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?
Dental History
Dentist Name:
Address:
City:
State:
Zip:
Has the patient had an orthodontic consultant or treatment?
No
Yes
If so, when?
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
*Please answer the following questions. (Cannot be left blank.)
No
Yes
Speech problems/therapy?
No
Yes
Grind or clench teeth?
No
Yes
Oral habits (thumb/finger sucking, nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Neck/shoulder pain?
No
Yes
Frequent sore throats?
No
Yes
Excessive bleeding following extractions?
No
Yes
Trouble associated with previous dental work?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently chew gum?
No
Yes
Periodontal/gum treatment?
No
Yes
TMJ/jaw joint treatment?
Please provide necessary explanations below:
Medical History
Physician Name:
Address:
City:
State:
Zip:
Date of last Physical:
Patient Health:
Good
Excellent
Fair
Poor
*Please select YES if the patient has had any of the conditions listed below either now or in the past.
No
Yes
Rheumatic Fever
No
Yes
Tuberculosis/Lung Disease
No
Yes
Pneumonia
No
Yes
Liver Disease
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Heart Murmur
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
Tonsils/Adenoids Removed
No
Yes
(Women) Are you pregnant?
If pregnant, please give due date
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Growth Problems
No
Yes
Endocrine Problems
No
Yes
Hormone Therapy
No
Yes
Latex/Metal Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Handicaps/Disabilities
No
Yes
Asthma
No
Yes
Arthritis
No
Yes
Treated for Emotional Problems
No
Yes
Ever Been Hospitalized
No
Yes
Do you use tobacco in any form?
If use tobacco, how much?
If any of the above medical questions were answered 'Yes' , please explain:
Is patient currently under the care of a physician? Please explain:
Are you currently or have you ever taken any bisphosphonate medications for the treatment of bone loss? (ie. Actonel, Boniva, Phosomax, Reclast, etc.) If YES, please explain:
List any other medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Spouse's Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Employer:
Occupation:
Work Phone:
Who will be financially responsible for the treatment?
Self
Spouse
Other
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Main Phone:
*Cell Phone:
*Email:
Relationship to Patient:
Self
Spouse
Other
If other:
Employer:
*Occupation:
Work Phone:
Would you like us to provide you with insurance forms?
No
Yes